Published on July 6, 2009
Congestive Heart Failure (CHF) : Congestive Heart Failure (CHF) Christopher George, BSN, CCRN, CEN, NREMT-P Objectives : Objectives Define Congestive Heart Failure (CHF) Provide an overview of CHF including: pathophysiology, symptoms, and diagnosis Describe current treatment options Discuss the nursing role in caring for patients affected by CHF What is CHF? : What is CHF? The inability of the heart to pump with enough force to meet the metabolic demands of the body (Canobbio, 2006) 23 million people with heart failure worldwide (Fuster et al, 2004) Synonymous with systolic heart failure Photo retrieved from http://fromyourdoctor.com/vivacardio/health/topic.do?title=Heart+Failure+Congestive+Heart+Failure&t=7967 Stages of CHF : Stages of CHF Stage A: Ordinary physical activity does not cause abnormal fatigue, palpitations or dyspnea Stage B: Comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnea (Baliga & Eagle, 2008) Photo retrieved from http://www.jems.com/news_and_articles/columns/Edgerly/the_stages_of_heart_failure.html Stages of CHF (cont.) : Stages of CHF (cont.) Stage C: Comfortable at rest, but even mild activity results in fatigue, palpitations or dyspnea Stage D: Uncomfortable at rest, advanced disease requiring hospital-based support (Baliga & Eagle, 2008) Acute Decompensated CHF : Acute Decompensated CHF Definition: Abrupt increase in worsening of CHF, with a prior diagnosis of CHF OR Abrupt onset of CHF without prior diagnosis. (Mebazaa, Gheorghiade, Zannad, & Parrillo, 2004) These are rapid changes, usually require activation of Emergency Medical Services Risk Factors : Risk Factors Age History of Myocardial Infarction History of Hypertension History of Diabetes History of Valvular Heart Disease Obesity (Fuster et al, 2004) Signs of CHF : Signs of CHF Tachypnea Respiratory Distress Rales/Crackles on auscultation Gallop Rhythms (Fuster et al, 2004) Symptoms of CHF : Symptoms of CHF Shortness of Breath Orthopnea Paroxysmal Nocturnal Dyspnea Pink “Frothy” sputum production (Mebazaa, Gheorghiade & Zannad, 2004) Photo retrieved from http://odyb.net/physical-health/9-types-of-diseases-caused-by-obesity/ Causes of CHF : Causes of CHF Ischemic Heart Disease Cigarette Smoking Hypertension Obesity Diabetes (Fuster et al, 2004) Acute Decompensated CHF Causes : Acute Decompensated CHF Causes Acute Myocardial Infarction Infection Fluid overload Usually IV Fluids Renal failure (Hosenpud & Greenberg, 2006) Pathophysiology of CHF : Pathophysiology of CHF Reduced contractility of the heart Preload or left ventricular end diastolic volume (LVEDV) increases This increase in end diastolic volume causes dilation of left ventricle and a further increase in LVEDV. (Fuster et al, 2004) Pathophysiology : Pathophysiology Photo retrieved from: https://www.bcbsri.com/BCBSRIWeb/images/mayo_popup/Leftventricularhypertrophy.jsp Pathophysiology : Pathophysiology Photo retrieved from: http://www.cardiomyopathy.org/images/illustrations/dcm-fig2.jpg Pathophysiology : Pathophysiology Click to watch movie Movie retrieved from:http://video.google.com/videoplay?docid=3621542645444015856&ei=kJVGSsbWMaWUrAK66IimDg&q=CHF&hl=en&client=safari Download windows media player here Pathophysiology : Pathophysiology Myocardium cannot compensate for continued stretching Starlings law Cardiac output falls Renal perfusion diminishes Increase in plasma volume (Greene & Harris, 2008) Pathophysiology : Pathophysiology Decrease in contractility Increase in preload Increase in afterload Progressively weakening left ventricle Starts to back up Pulmonary congestion, inadequate systemic perfusion Usually seen as hypotension (McCance & Huether, 2006) Assessment : Assessment Heart sounds S3-click to listen S4-click to listen Mitral valve regurgitation-click to listen Daily Weights Pink “frothy” sputum Photo retrieved from: http://www.bioen.utah.edu/faculty/sri/Lab8_humancardiovascular.htm Assessment : Assessment Lung sounds Rales/Crackles- click to listen Wheezes-click to listen (Swartz, 2006) Photo retrieved from: http://nursetalk.wordpress.com/ Diagnosis : Diagnosis Echocardiogram Chest X-ray EKG Blood Tests- BNP Angiography Photo retrieved from: http://www.mikety.net/Projects/algor0.html (Goroll & Mulley, 2009) Clinical Diagnostics : Clinical Diagnostics Echocardiogram Ejection Fraction less than 50% B-Naturetic Peptide Greater than 100 pg per milliliter in CHF Chest X-Ray Will show fluid around lungs, and enlargement of heart….not a definative test. (Wallach, 2007) Treatment (Acute) : Treatment (Acute) Pain management- Morphine Reduce anxiety, decreases cardiac oxygen demand Airway support- Supplemental oxygen, intubation, Bipap Intra aortic balloon pump Will inrease cardiac ouptut by approximately 15-20% Used in refractory CHF (Hosenpud & Greenberg, 2006) PTCA Used when cause is ST elevation MI, or non STEMI. (Baliga & Eagle, 2008) Treatment (Acute) : Treatment (Acute) Diuretic treatment- Lasix Edema Vasodilators- Nitroglycerin “opens up the tank” Vasopressors- Dobutamine Increases LV function Milrinone (Fuster et al, 2004) Treatment (Chronic) : Treatment (Chronic) Cardiac Glycoside (digoxin) Diuretics (lasix, spironolactone) Beta Blockers (lopressor, atenolol) (Fuster et al, 2004) Treatment (Chronic) : Treatment (Chronic) CABG Valve repair Heart transplant (Fuster et al, 2004) Lifestyle Changes : Lifestyle Changes Diet Exercise Smoking cessation Weight reduction (Mebazaa, Gheorghiade, Zannad, & Parrillo, 2004) The Nurse’s Role in CHF Treatment : The Nurse’s Role in CHF Treatment Manage the acute event Educate Medication regimen Exercise Weight loss Diet Photo retrieved from: http://nursetalk.wordpress.com/ (Lamprecht, 2007) The Nurse’s Role in CHF Treatment : The Nurse’s Role in CHF Treatment Chart retrieved from: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1876347&blobtype=pdf The Nurse’s Role in CHF Treatment : The Nurse’s Role in CHF Treatment Psychological concerns Social Service involvement (Lamprecht, 2007) Image retrieved from: http://www.jems.com/news_and_articles/articles/jems/3402/mastering_chf.html Case Study : Case Study A 68-year-old male presents to arriving paramedics complaining of shortness of breath for the last two days with a past medical history of myocardial infarction. Over the last several months the patient has had shortness of breath while working out in his yard, and walking up stairs. He has noticed swelling of his lower legs. For the past week he has awaken early in the morning short of breath. The patient has then used several more pillows to sleep in a reclined position. He has just returned from a family birthday party where he ate a large ham and potato dinner. During this time he had several beers with his friends and family. Case Study Physical Exam : Case Study Physical Exam BP 238/92?P 144, irregular?Respiratory Rate 38 and labored?Temp 100.1°F?Ht: 5'8"?Wt: 240. Oxygen Saturation 81% on room air General: Breathless, obese male acute distress sitting upright in tripod position HEENT: Neck: Distended neck, JVD present. Carotids no bruits noted. Chest: Scattered wheezes throughout, rales bilateral two thirds up lung field. Cough is productive pink and frothy. Tachycardia irregular. S3 heart sound present. EKG shows rapid atrial fibrillation no ST elevation noted. ABD: Large round, distended bowel sounds present. Extremities. Good CSM, +2 pitting edema present. Case Study Quiz : Case Study Quiz 1. Why is this patient in respiratory distress? 2. What would be the first line treatment for this patient? 3. What would be the first medication administered to this patient? Case Study Quiz : Case Study Quiz 4. What does the S3 heart sound represent? 5.Upon arrival to the Emergency room which test would be most decisive in diagnosing CHF? Case Study Quiz Answers : Case Study Quiz Answers 1. This patient is in acute pulmonary edema. This has occurred most likely due to an underlying CHF history. This is not a complete acute event. This patient shows signs of right sided heart failure (swollen ankles) and history of disease (orthopnea for a week). Case Study Quiz Answers : Case Study Quiz Answers 2. The first line treatment would be supplemental oxygen. The paramedics would most likely give oxygen via non-rebreather. Some paramedics can deliver Cpap or Bipap treatment, if the patient does not respond to the NRB this would be appropriate. If all of this fails intubation would be required. Case Study Quiz Answers : Case Study Quiz Answers 3. The first medication to be given to this patient is nitroglycerin. Preferably IV nitro, if not sublingual nitro or nitro via a patch can be given. Because of the rapid vasodilatory effects nitro can deliver rapid relief. Next, Lasix would be given, followed by morphine. Case Study Quiz Answers : Case Study Quiz Answers 4. The presence of S3 heart sound represents an increase in blood volume present in the left ventricle. 5. B-Natriuretic Peptide- is both specific and sensitive for diagnosis of CHF CHF Quiz : CHF Quiz 1) Define Congestive Heart Failure. 2) Which stage of CHF will require hospitalization? 3) What is acute decompensated CHF? 4) What is the most common cause of acute decompensated CHF? 5) Which treatment is used in refractory CHF? 6) What is Starling’s Law? CHF Quiz : CHF Quiz 7) What will have to be monitored closely on a patient receiving Spironolactone? 8) What are the three ways that Milrinone works to treat CHF? 9) Rales/crackles is most frequently heard on lung auscultation in a patient with CHF. Which is the second most frequent? 10) Name 3 lifestyle changes that will help a patient diagnosed with CHF. Answers to CHF Quiz : Answers to CHF Quiz 1) The inability of the heart to pump with enough force to meet the metabolic demands of the body. 2) Stage D will require hospitalization. 3) Abrupt increase in worsening of CHF with a prior diagnosis of CHF, or an Abrupt onset of CHF without prior diagnosis. Answers to CHF Quiz : Answers to CHF Quiz 4) Acute Myocardial Infarction 5) Intra-aortic balloon pump 6) The greater the stretch of the cardiac muscles the greater the contraction. 7) Potassium levels Answers to CHF Quiz : Answers to CHF Quiz 8)Positive Inotropic, Vasodilitation, and minimal chronotropic effects. 9) Wheezing- from narrowing due to fluid overload 10) Smoking cessation, weight reduction, low sodium diet References : References Baliga, B. B., & Eagle, K. A. (2008). Practical cardiology: Evaluation and treatment of common cardiovascular disorders. (2nd ed.). New York: Lippincott Williams & Wilkins. Canobbio, M. M. (2006). Mosby's handbook of patient teaching. (5th ed.). St. Louis, MO: Elsevier Science. Fuster, V., Alexander, R. W., Hurst, J. W., O’Rourke, R. A., King, S. B., Nash, I., & Prystowsky, E. N. (2004). Hurst's the heart. (11th ed.). New York: McGraw-Hill Companies. Goroll, A. H., & Mulley, A, G. (2009). Primary care medicine: Office evaluation and management of the adult patient. (6th ed.). New York: Lippincott Williams & Wilkins. Greene, R. J., & Harris, N. D. (2008). Pathology and therapeutics for pharmacists: A basic for clinical pharmacy practice. (3rd ed.). London: Pharmaceutical Press. Hosenpud, J. D., & Greenberg, B. H. (2006). Congestive heart failure. (3rd ed.). New York: Lippincott Willaims & Wilkins. References : References Lamprecht, M. (2007, August, 23). The heart failure nurse: Improving the quality of life for CHF patients . Suite101.com: The genuine article. Retrieved June 25, 2009 from, http://patient-health-education.suite101.com/article.cfm/nurse_management McCance, K. L., & Huether, S. E. (2006). Pathophysiology: The biologic basis for disease in adults and children. (5th ed.). St. Louis, MO: Elsevier Mosby. McPhee, S. J., Papadakis, & M. A., Tierney, M. L. (2008). Current medical diagnosis and treatment. New York: McGraw-Hill Companies Mebazaa, A., Gheorghiade, M., Zannad, F. M., & Parrillo, J. E. (2004). Acute heart failure. London: Springer Swartz, M. H. (2006). Textbook of physical diagnosis: History and examination. (5th ed.). St. Louis, MO: Elsevier Science. Wallach, W., (2007). Interpretation of diagnostic tests. (8th ed.). Philadelphia: Lippincott Williams & Wilkins.